Healthcare Provider Details

I. General information

NPI: 1750317020
Provider Name (Legal Business Name): PLASTIC & HAND SURGERY ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FRANK SCOTT PKWY W #970
BELLEVILLE IL
62223-5000
US

IV. Provider business mailing address

2900 FRANK SCOTT PKWY W #970
BELLEVILLE IL
62223-5000
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-8500
  • Fax: 618-235-2929
Mailing address:
  • Phone: 618-235-8500
  • Fax: 618-235-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. AMORN SALYAPONGSE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-235-8500